Medway Maritime is changing. To cope with higher demand, the hospital, which serves 405,000, must adapt if it is to continue to improve following a lengthy spell in special measures. Ed McConnell sat down with chief executive James Devine to discuss the progress the hospital has made and where it goes from here.

At 16 James Devine left school and embarked on a youth training scheme at his local hospital.

Now, 22 years on, he sits opposite me explaining how that same hospital, which he now runs, is making good progress, nearly two years since it came out of special measures.

In between he's worked at various London trusts before returning to Medway as HR director in 2016 and taking over from Lesley Dwyer last year.

These days, the youth training scheme £160,000-a-year Mr Devine embarked on in 1996 would be called an apprenticeship.

There's currently 87 apprentices at Medway Maritime and he wants to get that up to 101, a figure which would mean once again the trust would spend its entire levy of £900,000.

"We were one of the only trusts in the country to do that last year," he proudly declares.

It's one of three things he says he's most proud of since starting his role, initially as a deputy, 18-months-ago.

The trust has different levels of apprenticeship in everything from administration to nursing and offers qualifications in association with Mid Kent College and Henley Business School all the way up to a masters degree.

He said: "As one of the biggest employers in the area we recognise we have a responsibility. One in five children in the Towns live in poverty. We've got a social responsibility to them."

It's not just youth employment Mr Devine's background makes him uniquely qualified to talk about.

He's lived in Medway his whole life, brought up in Chatham, Rochester and Rainham — where he now lives — and attending the old Temple School.

His passion for the Towns is, he hopes, shared by the trust's 4,500 staff, the vast majority of whom live here.

This means they're personally invested in a hospital they, along with 405,000 people across Medway and Swale, use.

It's the second thing he identifies as a source of particular pride and one which he witnesses on a daily basis as he walks the warren-like corridors of the former naval hospital.

"As one of the biggest employers in the area we recognise we have a responsibility. One in five children in the Towns live in poverty. We've got a social responsibility to them." — James Devine

He said: "They care about this organisation. When we don't get it quite right they take it personally. I'm immensely proud of that and the way they cope with high demand, especially during winter."

That leads on to his third key achievement, the Employer with Heart charter which Medway was the first trust in England to sign last year.

It gives parents with premature babies longer off when they are born and although it impacts a relatively small number of staff Mr Devine says he's had really positive feedback about it.

There's been a shift in the relationship between employers and staff in recent years, Mr Devine says, "it's now much more give and take".

The trust takes care of its staff and expects them to deliver the best standard of care to patients and it seems to be working.

The fact the Emergency Department has recently recruited two addition consultants is "virtually unheard of", while the strategy which resulted in a drop of the vacancy rate for nurses from 65% three years ago to just 3% has won awards.

That last figure is a remarkable turnaround which means Medway is now one of the few trusts in the country spending below the agency pay cap.

Many of those nurses are now working in the new £11.5 million Emergency Department, which opened at the end of last year.

It's the first of three phases of work which will eventually boost capacity to the level needed — before the new building opened its doors the department could handle 40,000 annual presentations, when the work is completed that will rise to 100,000.

That will improve the streaming system already in place, which aims to get patients assessed either as soon as they arrive in an ambulance or within 15 minutes if they're a walk in.

After that assessment only around 30% end up staying in A&E, about 40% are sent to MedOCC, the hospital's on-site GP, or to their own doctor, and another 30% go home.

But Mr Devine acknowledges despite obvious improvements, there's still a way to go.

Winter, as it is at any hospital, is a particularly challenging time and even a new Emergency Department and improved processes can only go so far.

There are still stories of unacceptable wait times, often for beds elsewhere in the hospital, as frustrating for staff as they are for patients.

While Mr Devine stresses ambulances are no longer queuing and patients are never treated in corridors, he's fully aware patients' journeys through the hospital can prove difficult.

Part of that is down to better communication, something a long overdue introduction of electronic medical records later this year will help with.

But a big element is also the way the hospital works with other agencies, such as Medway Community Healthcare and the council.

Mr Devine says: "My main goal is for the organisation to continue improving.

"We should absolutely shout about the good stuff we are doing, and I will do that. But we also need to keep looking at how we can get better."

Winter pressures

Winter is the hardest time for the health service, with cold weather and treacherous conditions resulting in a rise in respiratory conditions and broken bones.

Wait times — the period between arriving at A&E and leaving either through discharge or transfer — are another casualty, and inevitably increase at hospital's throughout the country.

At Medway the situation this year looks better than previously.

In December 89.1% of 10,489 A&E patients were dealt with in the targeted four hours, a vast improvement on 69% in 2017.

It's still some way short of the 95% NHS target.

James Devine is keen to shout about the trust's record for assessing the vast majority of patients within 15 minutes — the average when I was there was 13 minutes — but the process starts to fall down when it comes to getting people out of A&E.

If beds aren't free elsewhere in the hospital, patients are stuck in limbo.

Figures from the last two weeks of December show bed occupancy was at 97.4% and 98.9% respectively.

The British Medical Association says hospital's should aim for below 85%, while NHS Improvement says anything over 92% leads to significantly worse A&E performance.

At Medway an average day in the first week of January saw five beds free, of the 476 beds in use, more than half had been in use for more than a week and almost 20% for more than three.

In short, the biggest problem facing the hospital is what some refer to as 'bed blockers' — patients who are well enough to leave but for whom space in the community cannot be found.

The hospital apologised to all those having to wait longer than expected, especially those expecting to be moved to another part of the hospital but assured them staff were doing everything in their power.

Still to come

Next week, we hear more about the problem of bed occupancy from the staff dealing with it on a daily basis.

From those leading the hospital's Emergency Department, often referred to as its front door, to the people working tirelessly to get patients back home.

Negative reports surrounding some of the hospital's busier days last month and a stint at Opel 4 — the highest level of alert — left staff demoralised.

Speaking days after the Emergency Department's second busiest 24 hours ever, head of nursing Cliff Evans is keen to explain the complexities surrounding getting people in and out of the unit, his 19th in 30 years.

One of the patients we meet is 64-year-old father-of-six Thomas McGilloway who has just arrived by ambulance after experiencing chest pains.

His story demonstrates how the department's procedures kick in to action.

Elsewhere, head of site flow Michelle Mackie fights to free up beds, contending with lengthy waits for a bed to be moved mere metres in a pensioner's home and even one patient who simply doesn't want to leave.